Screening school-age children and adolescents for reduced vision caused by the need for spectacles

What is the aim of this review?
The aim of this Cochrane Review was to find out if vision screening of school-age children and adolescents reduces the number of children who need spectacles but who either don't have any or who are wearing the wrong prescription.

Key messages
Vision screening and provision of free spectacles improves the number of children who have and wear the spectacles they need. In lower-income settings, ready-made spectacles may provide a useful alternative to expensive custom-made spectacles.

What was studied in the review?
Worldwide, an unmet need for corrective spectacles is the leading cause of reduced vision in children; short-sightedness (unable to see objects in the distance clearly) has become the commonest eye condition. Reduced vision may affect academic performance and therefore choice of occupation and socio-economic status in adult life. It can also be associated with other symptoms such as headaches. Vision screening programmes designed to identify children who need spectacles have therefore been introduced into schools. Such programmes improve access to health care for some children who would not otherwise have it, but the value of these screening programmes is debatable. This review was therefore designed to collect and evaluate any evidence regarding how well such programmes are working.

What are the main results of the review?
Cochrane Review authors found seven relevant studies. These studies tested ways of improving the take-up of spectacle prescriptions given as part of a screening programme. Five studies were from China, one from India and one from Tanzania. These studies compared: vision screening with free spectacles with vision screening alone; vision screening with education with vision screening alone; and vision screening and ready-made spectacles with vision screening and custom-made spectacles.

The review shows that:

• There are no studies comparing vision screening with no vision screening (evidence gap).
• Vision screening with provision of free spectacles results in more children wearing spectacles after screening compared with giving the children a prescription on its own (high-certainty evidence). Children in the free-spectacle group had better educational attainment (low-certainty evidence).
• Vision screening with health education designed to increase spectacle uptake did not appear to improve the number of children wearing spectacles after screening compared with no education (moderate-certainty evidence).
• Ready-made and custom-made spectacles appear to give similar visual results and similar spectacle wearing (moderate- and high-certainty evidence).

How up-to-date is this review?
Cochrane Review authors searched for studies that had been published up to 3 May 2017.

Authors' conclusions: 

Vision screening plus provision of free spectacles improves the number of children who have and wear the spectacles they need compared with providing a prescription only. This may lead to better educational outcomes. Health education interventions, as currently devised and tested, do not appear to improve spectacle wearing in children. In lower-income settings, ready-made spectacles may provide a useful alternative to expensive custom-made spectacles.

Read the full abstract...
Background: 

Although the benefits of vision screening seem intuitive, the value of such programmes in junior and senior schools has been questioned. In addition there exists a lack of clarity regarding the optimum age for screening and frequency at which to carry out screening.

Objectives: 

To evaluate the effectiveness of vision screening programmes carried out in schools to reduce the prevalence of correctable visual acuity deficits due to refractive error in school-age children.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 4); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 3 May 2017.

Selection criteria: 

We included randomised controlled trials (RCTs), including cluster-randomised trials, that compared vision screening with no vision screening, or compared interventions to improve uptake of spectacles or efficiency of vision screening.

Data collection and analysis: 

Two review authors independently screened search results and extracted data. Our pre-specified primary outcome was uncorrected, or suboptimally corrected, visual acuity deficit due to refractive error six months after screening. Pre-specified secondary outcomes included visual acuity deficit due to refractive error more than six months after screening, visual acuity deficit due to causes other than refractive error, spectacle wearing, quality of life, costs, and adverse effects. We graded the certainty of the evidence using GRADE.

Main results: 

We identified seven relevant studies. Five of these studies were conducted in China with one study in India and one in Tanzania. A total of 9858 children aged between 10 and 18 years were randomised in these studies, 8240 of whom (84%) were followed up between one and eight months after screening. Overall we judged the studies to be at low risk of bias. None of these studies compared vision screening for correctable visual acuity deficits with not screening.

Two studies compared vision screening with the provision of free spectacles versus vision screening with no provision of free spectacles (prescription only). These studies provide high-certainty evidence that vision screening with provision of free spectacles results in a higher proportion of children wearing spectacles than if vision screening is accompanied by provision of a prescription only (risk ratio (RR) 1.60, 95% confidence interval (CI) 1.34 to 1.90; 1092 participants). The studies suggest that if approximately 250 per 1000 children given vision screening plus prescription only are wearing spectacles at follow-up (three to six months) then 400 per 1000 (335 to 475) children would be wearing spectacles after vision screening and provision of free spectacles. Low-certainty evidence suggested better educational attainment in children in the free spectacles group (adjusted difference 0.11 in standardised mathematics score, 95% CI 0.01 to 0.21, 1 study, 2289 participants). Costs were reported in one study in Tanzania in 2008 and indicated a relatively low cost of screening and spectacle provision (low-certainty evidence). There was no evidence of any important effect of provision of free spectacles on uncorrected visual acuity (mean difference -0.02 logMAR (95% CI adjusted for clustering -0.04 to 0.01) between the groups at follow-up (moderate-certainty evidence). Other pre-specified outcomes of this review were not reported.

Two studies explored the effect of an educational intervention in addition to vision screening on spectacle wear. There was moderate-certainty evidence of little apparent effect of the education interventions investigated in these studies in addition to vision screening, compared to vision screening alone for spectacle wearing (RR 1.11, 95% CI 0.95 to 1.31, 1 study, 3177 participants) or related outcome spectacle purchase (odds ratio (OR) 0.84, 95% CI 0.55 to 1.31, 1 study, 4448 participants). Other pre-specified outcomes of this review were not reported.

Three studies compared vision screening with ready-made spectacles versus vision screening with custom-made spectacles. These studies provide moderate-certainty evidence of no clinically meaningful differences between the two types of spectacles. In one study, mean logMAR acuity in better and worse eye was similar between groups: mean difference (MD) better eye 0.03 logMAR, 95% CI 0.01 to 0.05; 414 participants; MD worse eye 0.06 logMAR, 95% CI 0.04 to 0.08; 414 participants). There was high-certainty evidence of no important difference in spectacle wearing (RR 0.98, 95% CI 0.91 to 1.05; 1203 participants) between the two groups and moderate-certainty evidence of no important difference in quality of life between the two groups (the mean quality-of-life score measured using the National Eye Institute Refractive Error Quality of Life scale 42 was 1.42 better (1.04 worse to 3.90 better) in children with ready-made spectacles (1 study of 188 participants). Although none of the studies reported on costs directly, ready-made spectacles are cheaper and may represent considerable cost-savings for vision screening programmes in lower income settings. There was low-certainty evidence of no important difference in adverse effects between the two groups. Adverse effects were reported in one study and were similar between groups. These included blurred vision, distorted vision, headache, disorientation, dizziness, eyestrain and nausea.

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